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WP0037430
EnvironmentalHealth
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EL RANCHO
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21120
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4200/4300 - Liquid Waste/Water Well Permits
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WP0037430
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Entry Properties
Last modified
9/30/2019 9:03:44 AM
Creation date
12/5/2017 12:35:28 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0037430
PE
4366
STREET_NUMBER
21120
STREET_NAME
EL RANCHO
STREET_TYPE
RD
City
TRACY
Zip
95304-
APN
21318025
ENTERED_DATE
10/16/2017 12:00:00 AM
SITE_LOCATION
21120 EL RANCHO RD
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
Scanner
TSok
Supplemental fields
FilePath
\MIGRATIONS\E\EL RANCHO\21120\WP0037430.PDF
QuestysFileName
WP0037430
QuestysRecordID
3685023
QuestysRecordType
12
Tags
EHD - Public
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JOB ADDRESS: 21120 EI Rancho Rd,Tracy,CA 95304 PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commending with Section 7000)of Division 3 of the Business and <br /> Professions Code and my license is in full force and effect. <br /> License# 290813 Expiration Date 05-31-2018 <br /> Date 02-02-2017 Contractor Hennings Bros.Drilling Co..Inc. <br /> OWNER-BUILDER DECLARATION <br /> I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions <br /> Code: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure, prior to its issuance, <br /> also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's <br /> License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt <br /> herefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant <br /> to a civil penalty of not more than five hundred dollars($500)): <br /> D I, as owner of the property, or my employees with wages as their sole compensation,will do the work, and the structure is not <br /> intended or offered for sale (Section 7044, Business and Professions Code:The contractor's License Law does not apply to an <br /> owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that <br /> such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of <br /> completion,the owner-builder will have the burden of proving that he did not build or improve for the purpose of sale.) <br /> ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Section 7044,Business and <br /> Professions Code(B&PC): The Contractor's License Law does not apply to an owner of property who builds or improves hereon, <br /> and who constructs for such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) <br /> O I am exempt under Section , B&PC for this reason <br /> Date: Owner: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm that I have a certificate of consent to self-insure or a certificate of Workers'Compensation Insurance,or a <br /> certified copy thereof(Section 3800,Labor Code). <br /> Expiration Date 01-01-2018 Company Everest Mutual Insurance <br /> ❑Certified copy is hereby furnished <br /> ®Certified copy is fled with the Environmental Health Department <br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE <br /> (This section need not be completed if the permit is for one hundred dollars($100)or less) <br /> I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so <br /> as to become subject to the Workers'Compensation Laws of California- <br /> Date: Applicant <br /> NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation <br /> provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. <br /> CONSTRUCTION LENDING AGENCY <br /> I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued <br /> (Section 3097,Civil Code). - <br /> Lenders Name ' <br /> Lender Address <br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION <br /> O I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in <br /> connection with work authorized by the permit,and that no building structure,scaffolding,falsework,or demolition or dismantling <br /> thereof,will be more than thirty-six(38)feet high.(Chapter 3.2, Group 2,Article 2,Section 341,Titie 8,Califomia Administrative <br /> Code). <br /> O As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted <br /> above,unless such person has a permit to do such work from the division. <br /> O Division of Industrial Safety Permit# <br /> I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county <br /> ordinances and state laws relating to well construction and or sewage system Construction,and hereby authorize representatives of this <br /> county to enter upon the above-mentioned property for inspection purposes. <br /> Date Applicant <br /> EHD 43-07 LICENSED CONTRACTOR DECUBATION <br /> 101&07 <br />
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